Medical scheme beneficiaries

PMBs are very good news for medical scheme beneficiaries and give them considerable rights as far as healthcare is concerned. However, as a consumer you also have certain responsibilities to ensure that PMBs work as well for you as they should.

Medical schemes First and foremost, educate yourself about your medical scheme’s rules, the listed medication and treatments (formularies) for your specific condition, as well as who the Designated Service Providers (DSPs) are. Obtain as much information as possible about your condition and the medication and treatments for it. If there is a generic drug available, do your own research to find out whether there are any differences between it and the branded drug.

Don’t bypass the system
If you must use a GP to refer you to a specialist, then do so. Make use of your medical scheme’s DSPs as far as possible. Stick with your scheme’s listed drug for your medication unless it is proven to be ineffective.

Be a good consumer
Ask questions and follow the complaints process if you are not treated fairly.

Doctors an accounts
Make sure your doctor submits a complete account to the medical scheme. It is especially important that the correct ICD-10 code is reflected.

Follow up and check that your account is submitted within four months and paid within 30 days after the claim was received (accounts older than four months are not paid by medical schemes).

Medical schemes
Among other objectives, PMBs want to achieve appropriate healthcare, resulting in lower costs associated with complications and hospitalisation. When beneficiaries are properly taken care of and their illnesses managed, the need for expensive hospitalisation decreases.

Medical schemes have a critical role to play in making PMBs work. Schemes have to educate their beneficiaries about PMBs and the benefits that are included in them. Schemes must inform their beneficiaries of their DSPs and keep them updated should any changes occur. Schemes should empower their beneficiaries with information on matters such as the intricacies of rules and the formularies for specific conditions. Medical schemes have to guarantee and ensure reasonable access and availability of DSPs.
The public sector cannot be designated as a DSP without the medical scheme ensuring that the necessary service will be available.

Healthcare providers
Doctors do not usually have a direct contractual relationship with medical schemes, although this is starting to change with doctors joining scheme networks. Generally, doctors merely submit their accounts and if the medical scheme does not pay, for whatever reason, the doctor turns to the beneficiary for the amount due. This does not mean that PMBs are not important to healthcare providers nor that they don’t have a role to play in its successful functioning. Many doctors choose not to deal directly with medical schemes, and insist on cash payments. It is then up to the medical scheme member to negotiate payment with his/her medical scheme.

Doctors should familiarise themselves with ICD-10 codes and how they correspond with PMB codes. If you use the correct ICD-10 code your account will definitely be paid as PMBs enjoy guaranteed medical aid cover.
Consider on which option your patients are and what can realistically be covered before recommending a drug or treatment.

They should also alert patients to the fact that their condition is a PMB and encourage them to engage their medical scheme on the matter.

Doctors should keep proper clinical records of patients so that when a formulary drug or protocol is not effective, or causes adverse side-effects, you can justify your alternative recommendation.

Doctors should not abuse PMBs. The result will be an unsustainable private healthcare system with unaffordable contribution increases. Abuse could compel government to consider alternative payment options in the private healthcare sector.

Doctors should allow their practices to be listed as a DSP.

The “payment in full” concept is there to ensure accessibility of healthcare services for medical scheme beneficiaries if the DSP is not available; it is not a reimbursement model.

(Information from the Council for Medical Schemes)

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